Eyeworld

60 | EYEWORLD | AUGUST 2019 C ORNEA in glaucoma patients. They will often switch patients to regimens using preservative-free an- ti-glaucoma medications, however, they under- estimate the role of allergy with anti-glaucoma agents and the fact that the allergic reaction does not subside upon ending treatment with that drug," Dr. Maychuk said. The study performed at Fyodorov Eye Microsurgery Institution suggests that a large majority of patients with Thygeson's keratitis are positive for either cytomegalovirus or Ep- stein-Barr virus. Dr. Maychuk's treatment proto- col includes long-term, high-dosage, systemic antiviral drugs, like valacyclovir 1,500 mg/day for 3 months with topical cyclosporine 0.05%. Diseases associated with filamentary kera- titis include thyroid gland dysfunction, rheuma- toid arthritis, Sjögren's syndrome, and diabetes mellitus. "We found that many patients with severe dry eye did not develop filamentary keratitis, and we focus on concomitant diseases in these patients," he said. The causes of recurrences in cases of herpetic keratitis are often misunderstood. These include: dry eye, the lack of long-term reparative topical treatments, lack of standard tree branching pattern, and patients quitting treatment with artificial tears. According to Dr. Maychuk, recurrent erosions occur in 32% of all cases after primary herpes eye infection. "A problem in our country is to get patients to come back to the clinic with recurrences of herpetic keratitis," he said. Ulcerative keratitis in children results from chronic blepharitis, allergic conjunctivitis, and herpes infections. The problem in Russia is the limited access to ophthalmic care and the non-controlled use of antibiotics and antihista- mines. Some data reveal that the average time between infection and an ophthalmologist visit is 19 months. Treatment protocols now include antiviral systemic treatment, topical steroids, and topical cyclosporine. The incidence of cytomegalovirus infection in chronical recurrent keratitis was shown to be up to 83%, according to Russian investigations. Dr. Maychuk suggested that based on his data, cytomegalovirus could often be a cause of stro- mal keratitis. "Acanthamoeba is not a big issue in Russia, however, the problem is that doctors don't rec- ognize Acanthamoeba or Pseudomonas infections, as we in the hospitals receive infected patients in different clinical stages. We are trying to push doctors away from long-term treatments and encourage them to do keratectomy in cases when they suspect Acanthamoeba," Dr. Maychuk said. Viral keratitis Changes in the clinical picture of adenoviral keratoconjunctivitis occur every 3–4 years, seemingly affected by tourism in and out of Russia. Dr. Maychuk noted a large increase in infections after the 2014 Winter Olympics and more recently after the FIFA World Cup, both of which brought people from all over the world to Russia. "Russia is a closed ecological system, and we do not travel very much. Small, minor changes in the people coming into the coun- try affect how adenoviral keratoconjunctivitis occurs," he explained. According to Dr. Maychuk, a national sur- vey that included 24 ophthalmological centers and 2,400 patients showed pseudomembranes in adenoviral keratoconjunctivitis occur in 1/30 individuals; of these about 2% lead to severe fibrosis. "Russian ophthalmologists do not recog- nize pseudomembranes. Some feel challenged to remove them or think they might go away spontaneously. We included the removal of pseudomembranes in our national treatment protocol and are trying to push doctors to use surgical techniques on these pseudomembranes, especially for recurrences," he said. Data reveal that 1/17 patients with acute adenoviral infiltrates develop them again after a few weeks, even after treatment with cyclo- sporine 0.05%. Evidence suggests that PCR diagnostics do not show adenoviral DNA in conjunctival smears. A cytokine gene expression study in cultured cells of conjunctival scrapings suggests an ongoing immune inflammatory pro- cess. Therapy includes anti-inflammatory and immunosuppressive treatment for 6 months to increase the percentage of relapse-free flow. "National survey data reveal that Russian ophthalmologists diagnose a lot of dry eye continued from page 58 Financial interests Maychuk: None

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